Appendix A – Checklist

This fillable checklist can be completed and inserted into the patient medical record for patients starting or continuing a trial of opioid therapy.

Patient name Goals decided with patient (SMART goals: Specific, Measurable,
Pain diagnosis Agreed-upon, Realistic, Time-based)

Date of pain onset

Y N Date Notes
Has non-pharmacological therapy[i]
been optimized?
Has non-opioid pharmacotherapy[i]
been optimized?
Stable psychiatric disorder(s) or
mental illness?
Current or past substance use
disorder?

Cannabis use?

Thorough baseline assessment

conducted[ii] (as needed)?

Explained potential benefits[i]?

Explained adverse effects[i]?

Explained risks[i]?

Explained opioid safety[i]?

Informed consent obtained?

Signed treatment agreement[iii](as

needed)?
Patient given information
handout(s)[ii]?

Urine drug screening (as needed)?

Naloxone prescription (as needed)?

Which non-opioid pharmacotherapies have been optimized?
General: acetaminophen, nonsteroidal anti-inflammatory drugs
(NSAIDs)
Anticonvulsants: carbamazepine, gabapentin, pregabalin
Antidepressants: amitriptyline, duloxetine, fluoxetine
Topical: topical NSAIDs, topical rubifacients
Other:
Which non-pharmacological therapies have been optimized?
Physical activity: aerobic exercise, strengthening exercise, core
stabilizing exercise, Tai Chi, yoga, therapeutic aquatic exercise
Self-management programs
Psychological therapies: cognitive behavioural therapy,
mindfulness based interventions, acceptance and commitment
therapy, respondent behavioural therapies
Physical therapies: manual therapy, transcutaneous electrical
nerve stimulation, low level laser therapy
Other:

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Appendix B – Initiation, Maintenance & Monitoring Chart

This fillable table can be completed and inserted into the patient medical record for patients starting or continuing a trial of opioid therapy.

Patient name Goals decided with patient (SMART goals: Specific, Measurable, Agreed-upon,
Pain diagnosis Realistic, Time-based)

Date of pain onset

Date (patient seen)

Opioid prescribed

Daily dose, frequency and timing

MED

≥ 90 mg MED/day < 90 mg MED/day

Date of new dose to be administered

Goals achieved Yes No Partially

Pain intensity (Brief Pain Inventory ) [iv]

Functional status
Improved Worsened No Change

Adverse effects 0 = None

1 = Limits ADLs 2 = Prevents ADLs

Fatal overdose

Non-fatal overdose

Motor vehicle accident

Addiction

Sleep apnea

Osteoporosis

Drowsiness

Constipation

Dizziness/vertigo

Hypogonadism/sexual dysfunction

Vomiting

Nausea

Opioid induced hyperalgesia

Dry skin/pruritis

Other

Clinical features of
opioid use disorder[ii] Yes No

Urine drug screening Date Result

Naloxone prescription Yes No

Tapering offered Accepted Declined

Non-pharmacological
Yes No
therapies being used for pain

Non-opioid pharmacotherapy
Yes No
being used for pain
Legend: ADLs = activities of daily living, MED = morphine equivalent dose

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Appendix C – Switching Opioids

This appendix contains succinct steps and examples on how to switch opioid therapies, and fillable switching templates that can be completed and
inserted into the patient medical record. Tables are available for both switching methods.

Patient name Goals decided with patient (SMART goals: Specific, Measurable, Agreed-upon,
Pain diagnosis Realistic, Time-based)

Date of pain onset

Method 1 examples. Decrease the total daily dose of the current opioid by 25–50% and convert to new opioid equivalent dose.

Steps Example #1: Morphine and oxycodone/ Example #2: Hydromorphone to

acetaminophen to hydromorphone buprenorphine transdermal patch
1. Determine current opioid(s) regimen (e.g. • Morphine SR 90 mg tid • Hydromorphone CR 6 mg bid
opioid name, dose and frequency) • Oxycodone/acetaminophen 5/325 mg q 4 h • Hydromorphone IR 2–4 mg q 4 h prn (average
prn (averages 6 tabs/d, 2 tabs tid) 10 mg/d)
2. Calculate total daily dose of opioid(s) • Morphine 180 mg/d • Hydromorphone CR 12 mg/d
• Oxycodone 30 mg/d • Hydromorphone IR 10 mg/d
3. Convert the dose of each current opioid to • Morphine 180 mg/d x 1 = morphine 180 mg/d • Hydromorphone 22 mg/d x 5 = morphine 110
a MED • Oxycodone 30 mg/d x 1.5 = morphine 45 mg/d mg/d
4. Calculate total MED • Total MED = 225 mg/d • Total MED = 110 mg/d
5. Determine proportion of the initial daily dose • 50% = morphine 112.5 mg/d ☐ 50% = morphine 55 mg/d
that will be switched to the new opioid ☐ 60% = morphine 135 mg/d • 60% = morphine 66 mg/d
• 75% = morphine 169 mg/d • 75% = morphine 82.5 mg/d
Determine total MED that will be switched to
the new regimen • Other: • Other:

Note: Reduce the calculated dose by 25–50%

to minimize the risk of inadvertent overdose;
the amount reduced will depend on the
patient’s pain, adverse effects, hyperalgesia,
and reason for switching opioid
6. Calculate the daily dose of the new opioid
using the daily MED
7. Delineate new opioid dosage regimen (e.g.
dose, name, frequency and quantity)
8. Discontinue previous opioid prescriptions
Ask patient to give any unused opioid
prescriptions to their pharmacy for
appropriate disposal
9. Follow up
• 60% = morphine 135 mg/d • 50% = morphine 55 mg/d
• MED to hydromorphone: morphine 135 mg/d x • MED to buprenorphine transdermal
0.2 = hydromorphone 27 mg/d patch: morphine 46 mg/d approximately =
buprenorphine transdermal patch 20 μg/h q
7 days
• Hydromorphone CR 12 mg bid M: 2 weeks • 1 buprenorphine transdermal patch 20 ug/h
• Hydromorphone IR 1 mg tid prn, M: 21 tablets every 7 days, M: 2 patches
• Note: It takes at least 3 days for
buprenorphine transdermal patch to reach
steady state
• Discontinue morphine SR 90 mg bid • Discontinue hydromorphone CR 6 mg bid
• Discontinue oxycodone/acetaminophen q 4 • Discontinue hydromorphone IR 2–4 mg q 4
h prn h prn
• Consider a 3-day follow-up to assess withdrawal symptoms and pain; contact the patient 3 days
after starting the new opioid to check for signs of over-sedation and to ensure that pain relief is
at least comparable to the pre-switch treatment
• Follow up with patient every 2–4 weeks

Legend: bid = twice a day, CR = controlled release, d = day, h = hour, IR = immediate release, M = Mitte (how much to dispense), MED = morphine equivalent dose, mg =
milligram, μg = microgram, prn = as needed, q = every, SR = sustained release, tab = tablet, tid = 3 times a day
Note: Doses in the examples in the above tables are approximations due to inter-individual variation.
Steps and examples in the above tables have been developed in part from a consensus of expert opinion.

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Method 1 fillable template. Decrease the total daily dose of the current opioid by 25–50% and convert to new opioid equivalent dose.

Steps
1. Determine current opioid(s) regimen (e.g. opioid name, Opioid name:
dose and frequency) Dose:
Frequency:
2. Calculate total daily dose of opioid(s) Opioid: mg/day
3. Convert the dose of each current opioid to a MED
x =

x =

x =

4. Calculate total MED MED:

5. Determine proportion of the initial daily dose that will be 50% = morphine: mg/day
switched to the new opioid
Determine total MED that will be switched to the new 60% = morphine : mg/day
regimen
75% = morphine: mg/day
Note: Reduce the calculated dose by 25–50% to minimize
the risk of inadvertent overdose; the amount reduced Other:
will depend on the patient’s pain, adverse effects,
hyperalgesia, and reason for switching opioid
6. Calculate the daily dose of the new opioid using the daily New opioid dose:
MED
7. Delineate new opioid dosage regimen (e.g. dose, name, Opioid name:
frequency and quantity) Dose:
Frequency:
Quantity:
8. Discontinue previous opioid prescriptions Discontinue:

Ask patient to give any unused opioid prescriptions to Discontinue:

their pharmacy for appropriate disposal
9. Follow Up 3-day follow-up to assess withdrawal symptoms and pain:

week follow-up:

week follow-up:

Legend: MED = morphine equivalent dose, mg = milligram

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Method 2 (Cross Taper Method) example. Decrease the total daily dose of the current opioid by 10 –25% per week while titrating up the total daily
dose of the new opioid weekly by 10 –20% with a goal of switching over 3–4 weeks (also consider dose formulations available).
• Consider more regular (e.g. weekly) follow-ups, weekly dispensing and/or dosette/blisterpack if required.

Current opioid(s) New opioid(s)

Example #1 • Morphine SR 60 mg tid • Hydromorphone 24 mg/d
• Oxycodone/acetaminophen 5/325 mg q 4 h prn (averages 6
tabs/d, 2 tabs tid)
Week 1 • Discontinue oxycodone/acetaminophen 5/325 mg tablets • Add hydromorphone CR 3 mg bid
• Morphine SR 45 mg tid
Week 2 • Morphine SR 30 mg tid • Hydromorphone CR 6 mg bid
Week 3 • Morphine SR 15 mg tid • Hydromorphone CR 9 mg bid
Week 4 • Discontinue morphine SR 15 mg tid • Hydromorphone CR 12 mg bid

Legend: bid = twice a day, CR = controlled release, d = day, h = hour, mg = milligram, prn = as needed, q = every, SR = sustained release, tab = tablet, tid = 3 times a day
Note: Doses in the examples in the above table are approximations due to inter-individual variation.
Steps and examples in the above tables have been developed in part from a consensus of expert opinion.

Method 2 fillable template. Decrease the total daily dose of the current opioid by 10 –25% per week while titrating up the total daily dose of the
new opioid weekly by 10 –20% with a goal of switching over 3–4 weeks (also consider dose formulations available).
• Consider more regular (e.g. weekly) follow-ups, weekly dispensing and/or dosette/blisterpack if required.

Current opioid(s) New opioid(s)

Week 1 (Titrate down) Opioid name: (Add) Opioid name:
Dose: Dose:
Frequency: Frequency:
Week 2 (Titrate down) Opioid name: (Titrate up) Opioid name:
Dose: Dose:
Frequency: Frequency:
Week 3 (Titrate down) Opioid name: (Titrate up/remain the same ) Opioid name:
Dose: Dose:
Frequency: Frequency:
Week 4 (Discontinue) Opioid name: (Titrate up/remain the same) Opioid name:
Dose: Dose:
Frequency: Frequency:

See the Morphine Equivalence table, Suggested Initial Dose and Titration for Buprenorphine Transdermal Patch table and Suggested Initial Dose and Titration
for Buprenorphine/Naloxone Sublingual Tablets table from the main Opioid Manager tool for opioid conversations.

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Supporting Material
[i] Management of Chronic Non Cancer Pain - Appendices
cep.health/cncp
[ii] Management of Chronic Non Cancer Pain
cep.health/cncp
[iii] Opioid Medication Treatment Agreement
https://link.cep.health/om5
[iv] Brief Pain Inventory (BPI)
https://link.cep.health/om7

The Opioid Manager was developed by the Centre for Effective Practice (“CEP”) with clinical leadership from Drs. Andrea Furlan, Arun Radhakrishnan and Jose Silveira. In addition, the Opioid
Manager was informed by advice from target end-users engaged throughout the development process. The Opioid Manager was updated with funding from the University Health Network
(“UHN”).

The Opioid Manager was developed for licensed health care professionals in Canada as a guide only and does not constitute medical or other professional advice. Primary care providers and
other health care professionals are required to exercise their own clinical judgment in using the Opioid Manager. Neither the CEP, UHN, the contributors to the Opioid Manager, nor any of their
respective agents, appointees, directors, officers, employees, contractors, members or volunteers: (i) are providing medical, diagnostic or treatment services through the Opioid Manager; (ii)
to the extent permitted by applicable law, accept any responsibility for the use or misuse of the Opioid Manager by any individual including, but not limited to, primary care providers or entity,
including for any loss, damage or injury (including death) arising from or in connection with the use of the Opioid Manager, in whole or in part; or (iii) give or make any representation, warranty
or endorsement of any external sources referenced in the Opioid Manager (whether specifically named or not) that are owned or operated by third parties, including any information or advice
contained therein.

The Opioid Manager is a product of the CEP and UHN under copyright protection with all rights reserved to UHN. Permission to use, copy, and distribute printed copies
of the Opioid Manager and permission to link to a author webpage for the Opioid Manager, for all non-commercial and research purposes is granted, provided the above
disclaimer, this paragraph and appropriate citations appear in all copies, modifications, and distributions. Republishing digital materials via third-party websites or platforms
is prohibited. Use of the Opioid Manager for commercial purposes or any modifications of the Opioid Manager are subject to charge and use must be negotiated with the CEP
and UHN (Email: info@cep.health).

For statistical and bibliographic purposes, please notify the CEP (info@cep.health) of any use or reprinting of the Opioid Manager. Please use the below
citation when referencing the Opioid Manager:
Reprinted with Permission from the Centre for Effective Practice and University Health Network (November 2017). Opioid Manager. Toronto.
Developed by: In collaboration with:

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